Healthcare Provider Details

I. General information

NPI: 1306940739
Provider Name (Legal Business Name): KEVIN R MOORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MEDICAL DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

869 E 4500 S PMB 511
SALT LAKE CITY UT
84107-3049
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-1900
  • Fax:
Mailing address:
  • Phone: 801-487-0451
  • Fax: 801-487-2467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number273877-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: